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In this initial study, all but one of 21 patients who had RFA followed by SEMS placement maintained stent patency at 30 d. One patient had asymptomatic biochemical pancreatitis, 2 patients required percutaneous gallbladder drainage, and 1 Selleck ABT 737 patient developed rigors. At 90-d follow-up, 3 patients had occluded biliary stents. Subsequently, in a retrospective series of 12 patients (9 with CCA) with malignant intraductal or perihilar biliary strictures, Tal et al[80] performed 19 successful RFA applications via ERCP followed by PS placement. These investigators used a setting of 8 W for treatment of intrahepatic and perihilar biliary strictures and 10 W for extrahepatic bile duct strictures using an ERBE electrosurgical generator (VIO 200D, ERBE Elektromedizin, T��bingen, Germany). However, biliary bleeding was observed at 4-6 wk in 3 patients (2 of whom died of hemorrhagic shock), and cholangitis developed in 4 patients, which was amenable to stent exchange. Finally, Figueroa-Barojas et al[82] reported on the use of ERCP-directed RFA in 25 patients with malignant biliary structures (11 patients Thymidine kinase had CCA). Procedures were performed using a RITA 1500X RF generator (Angiodynamics, Latham, NY) set at 7-10 W for a time period of 2 min. These investigators reported a resultant significant increase in mean bile duct diameter of 3.5 mm (P Nutlin 3 by SEMS placement. They reported 100% technical success in both groups. While these investigators found that rates of stent patency were similar between the two groups, on multivariate analysis, RFA was found to be an independent predictor of survival (HR = 0.29, 95%CI: 0.11-0.76, P = 0.012). Finally, RFA has been described as a means of treating tumor ingrowth of uncovered SEMS in the bile duct[84]. Typically, the RFA catheter can be passed into a blocked stent and used under fluoroscopic guidance to ablate any tumor ingrowth, which is then removed by retrieval balloon sweep. This ablation may be followed by placement of an indwelling plastic stent or a second uncovered SEMS, in appropriate situations (Figure ?(Figure66). When compared to PDT, the advantages of endobiliary RFA include being able to provide ablative treatment without the patient having to come in 2 d in advance for infusion of a photosensitizer, easier delivery of the RFA catheter that can be done over a guidewire, and no requirement to avoid sunlight for several weeks to prevent photosensitivity.